Get Empowerchiro

Filling out the Empowerchiro Preferred Provider Application is an essential step for healthcare providers looking to join a preferred network. This guide provides clear, step-by-step instructions to help you navigate the online form efficiently.

Follow the steps to complete the Empowerchiro application online.

1. Click the ‘Get Form’ button to obtain the Empowerchiro Preferred Provider Application and open it in your editor.
2. Begin by entering your full name, gender, date of birth, Social Security number, Medicare number, and Medicaid number in the provided fields.
3. Complete the sections for your NPI Individual number, NPI Group number, primary email address, and webpage.
4. Fill in the W9/Legal Business Name and corresponding tax ID, along with your address, city, county/state/ZIP, phone number, and fax number.
5. Provide contact details for a specific person, including a contact email and office hours.
6. Complete the billing address section with the necessary information, ensuring to provide billing contact person details and email.
7. In the practice information section, indicate the techniques and special services you provide, languages spoken, patient acceptance policies, and availability for emergency care.
8. Detail your educational background, including the name of the chiropractic college, graduation date, and accreditation details.
9. List your employment history over the past five years, ensuring to explain any gaps in employment.
10. Provide licensure information for all current and past licenses, including the state and license number along with effective dates.
11. Answer all malpractice coverage questions, including insurance details, company information, and policy coverage.
12. Address any other information questions provided in the form with clarity.
13. Finally, read and sign the authorization, attestation, and release section, confirming that all your provided information is true and complete.
14. After completing the form, review all entries for accuracy. You can then save changes, download, print, or share the form as required.

Complete your Empowerchiro application online today to become a preferred provider!